Sample Directive: Determination of Incapacity & Appointment of an Agent

Personal Directive

I, _____________________________________________, of ______________, Alberta, do hereby:

  1. Designate ____________________________________, of ________________, Alberta to determine my incapacity in collaboration with a physician or psychologist.

  2. Appoint ___________________________________________, as my Agent; pursuant to the Personal Directives Act of Alberta. If (s)he predeceases me or is unavailable or unwilling to act, then I appoint __________________________________, to be my Alternate Agent. Any Agent appointed by me shall have full authority to make all personal and medical decisions for me in the event that a written declaration that I lack capacity is signed in accordance with the Personal Directives Act.

Capacity Assessor

Agent's name: ______________________

Agent's address:

____________________________________

____________________________________

____________________________________

Home Number: ______________________

Work Number: _______________________

 Agent

Agent's name: ______________________

Agent's address:

___________________________________

___________________________________

___________________________________

Home Number: ______________________

Work Number: ______________________

Note: the Act does not exclude the maker from naming the same person as the Agent and the Assessor.

 

Dated at ___________________ in the Province of Alberta, this _______ day of

_____________, 20___.

 

 _________________________________

Witness' Signature

 __________________________________

Maker's Signature

The appearance of this sample personal directive does not imply endorsement by the Provincial Health Ethics Network; it is provided for information purposes only. PHEN assumes no liability for any loss or damage suffered by any person by reason of their reliance on the information contained herein.